Valvular Heart Disease (Johnston) Flashcards
Grading of murmurs
I: so soft, barely heard
II: soft but easily heard
III: moderately loud, readily heard NO palpable thrill
IV: Palpable thrill, very loud
V: Palpable thrill, very loud even with stethoscope barely on chest wall
VI: Palpable thrill, can hear when you walk in room
Most common conditions associated with valvular disease and decline in what disease?
- MC: Degenerative (senile calcification), Myxomatous degernation (MVP), Congenital (bicuspid aortic valve)
- Decline in incidence of rheumatic valvular disease (RVD)
Valvular HD leads to
-Pressure or volume overload
Stenosis implies
- impeded foward flow
- stenotic, sclerosis, fibrosis, calcification
- Leads to pressure overload; hypertrophy and heart failure (HF)
- Example: Aortic Stenosis, Mitral Stenosis
Regurgitation implies
- Failure to close adequately (leaks):
- reversal of flow
- insufficiency, incompetence
- leads to volume overload; dilates
- Example: AI, MR
VHD can be
-congenital or acquired
Valvular dysfunction depends on? Examples?
- depends on tempo of disease onset (acute/chronic)
- Ex: Infective endocarditis–aortic cusp destruction leads to ACUTE AORTIC INSUFFICIENCY
- Ex: RHD complications develop over years; compensatory mechanism (CHRONIC)
RHD
- Due to RF
- RF–caused by group A strep infection (pharyngitis) virtually only cause of acquired MS (can be congenital)
- Jones major criteria: inflammation of heart muscle–myocarditis, pericarditis; migratory polyarthritis (large joints)–example: knees, hips, Subcutaneous nodules–painless over bone and tendon, Sydenhams chorea (st. vitus’s dance) rapid purposeless movement of face and arms; erythema marginatum
Jones minor criteria for RF
- Fever
- Arthralgia
- Increased Sed rate or CRP
- Leukocytosis
- ECG–prolonged PR
- Elevated ASO titer or anti DNase B
Diagnosis of RF
- two major criteria OR
- One major and 2 minor criteria
Mitral stenosis
- DIASTOLIC MURMUR! Best heard over APEX of heart
- Normal mitral valve orifice is 4-6 cm
- Narrowing leads to increased Left AV pressure gradient
- LAE (a fib, pul vascular changes, RVH)
- Orifice 1cm or less is severe that leads to pul HTN, RVF
Mitral stenosis symtoms
- 4th decade
- Dyspnea on exertion
- cough, orthopnea, PND, pulmonary edema, hemoptysis, arterial emboli
- A fib
Ortner syndrome
- Hoarsness d/+ compression of left recurrent laryngeal nerve bc Left atrium is so big
- Paralysis of vocal cord
- Associated with MITRAL STENOSIS!!
Mitral stenosis physical exam
- Malar flush: ruddy cheeks, blue facies
- Increase S1; opening shapes (OS) after S2
- Rumbling, diastolic murmur
- LOW PITCHED; BEST HEARD AT APEX
- USE BELL
Mitral stenosis treatment
- Anticoagulant if in atrial fibrillation
- Percutaneous balloon valvuloplasty MVR (replacement)
- Progressive symptoms–possible RVF
Why could patient that has MS develop progressive symptoms leading to RVF?
- Because everything backing up
- Left atrial pressure builds up, vascular resistance increases–>pulm HTN–>pulmonary artery pressure increases–>causing RVF (hepatomegalia, ascites, peripheral edema)
Cause of Mitral stenosis
-Most likely RHD!!
Most common etiology of Mitral regurgitation
- Mitral valve prolapse
- May also be caused by mitral annular calcification
Causes of acute mitral regurgitation
- Rupture of chrodae tendinae
- Rupture of papillary muscle
- Ischemic papillary muscle dysfunction due to CAD/MI
- Infective endocarditis; valve perforation
Second most common cause of mitral regurgitation
-CAD/MI–can lead to papillary muscle dysfunction and mitral regurg
Acute vs Chronic Mitral regurg
- Acute MR: increased LA pressure abruptly; pulmonary edema, LVF
- Chronic MR–generally well compensated
Mitral regurg symtoms
- Asymptomatic for years
- may have fatigue, DOE
- Acute MR: volume overload–orthopnea, PND, RHF/ LHF
What does a mitral regurg sound like on PE? systolic or diastolic?
- systolic murmur
- Blowing, prominent at apex; radiates into left axilla
- Loudness of murmur correlates with severity
- Decreased S1 or normal; may have systolic click
Treatment of MR
- Vasodilators–reduces after load
- Decrease resistance to flow
- ACEI–chronic MR
MVP and Mitral regurg
- One or both mitral leaflets will prolapse into LA during systole to cause MR
- MVP ratio is 7:1 female
MVP associated with what disease
-Marfan’s/skeletal changes
Symptoms of MVP
- Asymptomatic to arrhythmias (SVT, PVC, VT)
- Sometimes will see chest pain and syncope
- Systolic murmur; may have systolic click
Treatment of MVP
- If hyperadrenergic state (anxious, palpitations), consider beta blocker
- Valve repair favored over replacement
How to confirm MR in patient
- Heart Holter monitor!!
- Other tests: Echo, ECG, TSH, Free T4, CXR
Tx of MVP and thyroid disorder
- Beta blocker for hyper adrenergic state
- Regulate thyroid meds
Aortic stenosis Etiology
- Degenerative (calcific or senile)
- Congenital bicuspid aortic valve (BAV)
- 1% of population born with BAV
- Rheumatic or post inflammatory scarring
- Normal AoV is 4 cm
Aortic stenosis–where on heart? What does it sound like?
- 2nd intercostal space RSB
- Harsh, raspy, systolic murmur typically radiates into suprasternal notch up into the carotids
Pathophysiology of AS
- Obstruction leads to PRESSURE overload; LVH, increase LVED pressure
- Gradient across valve–the more the obstruction, the higher the gradient across the valve
Severe AS if
AoV is less than 1 cm
Symptoms of AS
-6th decade: exertional dyspnea, angina, syncope, heart failure
AS prognosis
- Without treatment prognosis is poor
- Without treatment most will die within 3 years of developing syncope and within 2 years of onset of HF
Hallmarks for AS
-ANGINA, SYNCOPE AND DYSPNEA!!!!
Physical Exam AS
-Narrow pulse pressure; decreased SV and systolic pressure
-Delayed pulses–Parvis/Tardus
-Systolic murmur
-Harsh 2nd ICS RSB; radiates into supra sternal notch/carotids
-
Gallvardin phenomenon
- associated with AS
- Murmur radiates into apex (like MR)
ECG associated with AS
-LVH (high voltage QRS in V6) with strain pattern
Treatment for AS
-Percutaneous balloon valvuloplasty–temporary AVR (aortic valve replacement)
Tests needed to diagnose AS
- Echo, ECG, CXR, Cardiac enzymes
- Echo–AoV area 1 cm–Diagnosis severe AS
Aortic Regurg causes
- Due to leaflet abnormalities (bicuspid AoV, IE)
- Due to aortic root abnormalities (Marfans, aortic dissection, aging, HTN)
- may also be from vegetations
Causes of acute AR
IE aortic dissection BAV Acue pulmonary edema cardiogenic shock
Causes of chronic AR
- Syphillis
- Ankylosing spondylitis–seronegative orthropathy
- develops over time and will see dyspnea, orthopnea, PND, chest pain!
AR systolic or diastolic? Heard where?
- soft DIASTOLIC murmur
- 2nd intercostal space, LSB
Pathophysiology AR
-Volume overload can increase LVEDV, LVH, left sided HF
Symptoms of AR
-Depends on rapidity of onset
Physical exam findings of AR
- Wide pulse pressure–ex: 140/60
- De Musset sign–head bobs bc of forceful systolic beat
- Corrigans pulse-rapid water hammer pulse
- Quinckes pulse-pulsations at nail bed
- Traube’s sign–pistol shot type of sound
- Durozrey’s sign-when compressing artery hear to and fro murmur over those arteries
- Hills sign–systolic BP higher in legs than in arm
- Bisferious pulse–double peak to pulse
- Meullers sign–can see uvula at back of throat moving with each systolic beat
Physical exam AR–sounds, found where
Diastolic
- decrescendo murmur
- 3rd ICS LSB
- systolic murmur usually present but soft
- Austin Flint murmur; Can mimic MS
Hallmark for AI
- DIASTOLIC MURMUR
- 3RD ICS LSB
- sometimes also associated with systolic murmur
- can mimic MS–called Austin Flint murmur
Treatment for AR
- ARB–Decreases after load to decrease regurg volume
- Surgery AoVR when symptomatic or EF less than 55%
CT of chest used for
-Aortic dilation
Tricuspid stenosis associated with
- Mitral stenosis
- TR
- Rheumatic Heart disease
Pathophysiology of tricuspid stenosis
-Prominent A wave in JVP–ascites, hepatomegalia (may pulsate)
Tricuspid stenosis—what kind of murmur? Systolic or diastolic?
-Diastolic murmur LSB; increase with inspiration (Carvallo’s sign) and decrease with expiration and valsalva
Tricuspid Regurgitation associated with?
- Pulmonary hypertension
- Inferior MI/RV infarction
Pathophysiology of TR
-Prominent V wave in JVP
TR sounds like? Systolic or diastolic?
-Blowing systolic murmur LSB; increases with inspiration (Carvallo’s sign)
Causes of pulmonary stenosis
- Atresia
- Congenital
Pulmonary stenosis can cause
-Angina and syncope
Auscultation of pulmonary stenosis
- systolic murmur, ejection click
- 2nd-3rd ICS, LSB/ radiates toward left shoulder and increases on inspiration/RVH
Pulmonary stenosis associated with what disorders
-TOF or TGA
Pulmonary stenosis treatment
-May require balloon commissurotomy if pressure gradient > 50mm Hg
Pulmonic regurgitation (PR or PI)–causes? Sounds like? Systolic or diastolic?
- Most cases are due to pulmonary HTN
- Diastolic blowing murmur 2nd SB (Graham Steell)
Systolic murmurs:
- Mitral regurg (MVP)
- Tricuspid Regurg
- Aortic Stenosis
- Pulmonary stenosis
- VSD
- Aortopulmonary shunts (early, mid, late, holosystolic/pansystolic)
Diastolic murmurs:
- Aortic Regurg
- Pulmonary Regurg
- Mitral stenosis
- Tricuspid stenosis
- Atrial myxoma
Continuous murmurs
- PDA–machinery
- AV fistula
- ASD with high LA pressure
- Coarctation
